ABP-Dental and Dental Plus Plan Details

Dental and Dental Plus Plan Details

Page Content

​Dental benefits include coverage for preventative and diagnostic treatments to help plan members and their
dependents pay for eligible dental procedures that are provided by a licensed dental professional.

Dental Plus is enhanced coverage that includes Major Services for procedures such as crowns and bridges
and, after a one year waiting period, orthodontic coverage. This waiting period is in place to prevent antiselection
of the plan.

Co-insurance for health and dental insurance refers to the portion that is paid by the insurance company.
For example, a 90% co-insurance means the insurer pays 90% and you pay 10%.
The plan year for Dental and Dental Plus is January 1st to December 31st. You have 180 days after the end of the benefit year (December 31st) to submit your claim expenses that were incurred during that benefit year.

Dental

Dental Plus

Plan Maximum (Lifetime Reimbursement)

$1,500 per Insured person for each plan year for all covered services

Basic & Preventative Services

Combined maximum $2,000 per Insured person for each plan year

Major Dental Services

$1,500 per Insured person for each plan year

If coverage starts July 1st or later, the maximum amount for that plan year will be reduced by 50%.

Basic and Preventative Dental Procedures

Dental benefits include the following procedures used to help prevent dental problems covered at 80% of the eligible expenses.

These are procedures that a dentist performs regularly to help maintain good dental health:Oral Examinations

1 complete examination every 24 months

1 recall examination every 9 months

Emergency or specific examinations

X-rays

X-rays (to diagnose a symptom or examine progress of a particular course of treatment)

1 set of bitewing x-rays every 9 months.

1 complete series of x-rays or 1 panorex every 24 months.

Other Services

Scaling and polishing (cleaning of teeth) and topical fluoride treatment once every 9 months

Oral hygiene instruction once per lifetime

Dental Plus benefits include the following procedures used to help prevent dental problems covered at 90% of the eligible expenses.These are procedures that a dentist performs regularly to help maintain good dental health:Oral Examinations

1 complete examination every 24 months

1 recall examination every 6 months up to maximum of 2 examinations per plan year

Emergency or specific examinations

X-rays

X-rays (to diagnose a symptom or examine progress of a particular course of treatment)

1 set of bitewing x-rays every 6 months up to a maximum of 2 sets per plan year.

1 complete series of x-rays or 1 panorex every 24 months.

Other Services

Scaling and polishing (cleaning of teeth) and topical fluoride treatment once every 6 months up to a maximum of 2 sets per plan year

Oral hygiene instruction once every 6 months up to maximum of 2 sessions per plan year

Other services

Emergency or palliative services

Diagnostic tests and laboratory examinations

Removal of impacted teeth and related anesthesia

Provision of space maintainers for missing primary teeth (only for dependent children who have not attained their 19th birthday)

Pit and fissure sealants (only for dependent children who have not attained their 19th birthday)

Interceptive, interventive or preventative orthodontic services other than space maintainers

Comprehensive orthodontic treatment using a removable or fixed appliance or combination of both. This includes diagnostic procedures, formal treatment and retention

Major Dental Procedures

Not included

Dental Plus benefits include the following procedures used to treat major dental problems covered at 60% co-insurance of the eligible expenses for these procedures:

Major Restorations

Inlays and onlays

Crowns and repairs to crowns and other prefabricated metal restorations

Repair of bridges

Prosthodontics

Construction and insertion of bridges or standard dentures

Coverage is limited to teeth extracted while insured person is covered under the plan.

Charges for a replacement bridge or replacement standard denture are not considered an eligible expense during the 5 year period following the construction or insertion of a previous bridge or standard denture unless:

It is needed to replace a bridge or standard denture which has caused temporomandibular joint disturbances and which cannot be economically modified to correct the condition

It is needed to replace a transitional denture which was inserted shortly following extraction of teeth and which cannot be economically modified to the final shape required

Extension of Benefits

If your coverage is terminated, any expenses incurred after the termination date are not covered, even if the treatment was pre-approved. The plans will cover expenses incurred within 31 days after the termination of your coverage if an insured person has started;

Dental restoration in connection with crowns or bridges for which the tooth was prepared prior to the termination date, or

Root canal therapy where the pulp chamber was opened prior to the termination of insurance, and your Dental or Dental Plus plan included coverage for these services prior to termination.

You will still be covered for procedures to repair natural teeth damaged by an accidental blow if the accident occurred before termination of coverage and the procedure is performed within 6 months after the date of the accident.

Survivor Benefit

If you die with no insured Dependent Spouse but with insured Dependent Child(ren), such coverage for the Dependent Child(ren) will be continued without payment of premium but will terminate on the earliest of the following circumstances:

termination of this plan;

12 months from the date of your death.

Note: If you die and have an insured Dependent Spouse, your spouse will have 60 days to become insured as an Independent Person and he/she will be able to continue coverage on insured Dependent Child(ren)

What is not covered

Covered expense shall not include any charges incurred directly for, as a result of, any one or more of the following:

Procedures or supplies used in full mouth reconstructions (capping all of the teeth in the mouth), vertical dimension corrections (changing the way the teeth meet) including attrition (worn down teeth), alteration or restoration of occlusion (building up and restoring the bite), or for the purpose of prosthetic splinting (capping teeth and joining teeth together to provide additional support)

Services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program unless explicitly listed as covered under this benefit

Services or supplies that are not usually provided to treat a dental problem

Procedures performed primarily to improve appearance

The replacement of dental appliances that are lost, misplaced or stolen

Charges for appointments that you do not keep

Charges for completing claim forms

Services or supplies for which no charge would have been made in the absence of this coverage

Supplies usually intended for sport or home use, for example, mouth guards

Charges related to implants, including surgery charges

Transplants and reposition of the jaw

Experimental treatments

The plan will also not pay for dental work resulting from:

The hostile action of any armed forces, insurrection or participation in a riot or civil commotion

Participation in a criminal offence

Teeth malformed at birth or during development

For details on converting between Dental and Dental Plus, see your benefits booklet or contact one of our OMA Insurance Service Representatives who will be happy to help you.​